Health inspection·October 10, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00857495. Representing the Department, HFEN # 45524 A citation was written F678 Code of Federal Regulations, Title 42, Section 483.24(a)(3). Quality of Life. Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 8/25/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident death. The facility failed to ensure Licensed Vocational Nurse 3 (LVN 3), performed cardio pulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) for Resident 1 in accordance with the facility's undated policy and procedures (P&P) titled "Manual Ventilation" and undated document titled "Chest Compressions", and the American Heart Association (AHA - organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths) Algorithm (a process or set of rules to be followed in calculations or other problem-solving operations) titled "Adult Basic Life Support Algorithm for Healthcare Providers" for the year 2020 to implement 30 chest compressions and two breaths. Certified nursing assistant 1 (CNA 1) found Resident 1 in bed and unresponsive on 7/18/2023 at 7:35 am. During CPR, LVN 3 placed a non-rebreather mask (a medical device used to deliver oxygen in emergencies to patients who are not able to breath on their own) and administered oxygen at 15 Liters/minute (L/min, unit of measurement) when Resident 1 was not breathing. As a result, there was lack of oxygenation (the loss or absence of oxygen supply to body tissues) and perfusion (the passage of fluid/blood through the circulatory system [blood stream] to vital body organs) for Resident 1. The paramedics (medical professionals who specializes in emergency treatment) transferred Resident 1 to General Acute Care Hospital (GACH) via emergency service (911- emergency telephone number to request emergency assistance) on 7/18/2023 at 7:43 a.m. Resident 1 died two days later at the GACH. A review of Resident 1's admission's record (Facesheet) indicated Resident 1 was initially admitted to the facility on 6/21/2023 and readmitted on 7/15/2023 with diagnoses including emphysema (a lung condition that causes shortness of breath), other unspecified respiratory (relating to or affecting respiration or the organs of respiration) disorders, Obstructive sleep apnea (occurs when the muscles in the back of the throat relax too much to allow for proper breathing), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm [heart beating too fast or to slow]) heart failure, and other heart-related complications. A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/18/2023, indicated the resident had severely impaired cognition (never/rarely makes decisions). The same MDS further indicated Resident 1 required one-person physical assist with bed mobility, transfer, locomotion on unit, dressing, eating and toilet use. A review of the nurses' notes dated 7/18/2023 indicated CNA 1 found Resident 1 found unresponsive on 7/18/2023 at 7:35 a.m. CNA 1 summoned LVN 3 who then assessed Resident 1. CPR was immediately initiated by LVN 1, oxygen at 15 liters per minute (LPM) on Resident 1 at 15 Liters using a nonrebreather mask by LVN 3. 911 was called immediately. Resident 1 was transferred to a GACH via emergency services on 7/18/2023 at 7:45 a.m. A review of the 911 run sheet dated 7/18/2023 indicated, the paramedics arrived at the facility at 7:33 am and began CPR interventions and began airway interventions for Resident 1 via Bag Valve Mask (BVM-ambubag). It further indicted that Resident 1 was in asystole (when your heart's electrical system fails, causing your heart to stop pumping) and apneic (when a person stops breathing). During an interview with CNA 1, on 8/31/23 at 10:27 a.m., CNA 1 stated that on 7/18/2023, she was passing the breakfast tray to Resident 1's roommate when she noticed that Resident 1 did not say "hi" to her [CNA 1] as he usually does. CNA 1 stated she tried to wake up Resident 1 and noticed that Resident 1 was unresponsive. CNA 1 stated she then pulled the call light (remote control device used as a primary method of patient-nurse communication) and yelled for help and that LVNs 1 and 2 came in to assist Resident 1. During an interview with LVN 1 on 8/31/23 at 10:56 a.m., LVN 1 stated she responded to CNA 1's call at 7:35 a.m. for help and that upon assessment, Resident 1 did not have a pulse (heartbeat) and no rise and fall of the chest (indicates if a person is breathing in and out). LVN 1 stated she immediately initiated CPR with chest compressions and a non-rebreather mask was placed on Resident 1. LVN 1 stated a non-rebreather mask delivers a higher amount of oxygen at between 5 and 15 liters. LVN 1 confirmed and stated a non-rebreather mask is used for people that are able to breath unassisted. LVN 1 further stated a patient would not be able to breath and receive oxygen if a non-rebreather mask is placed on a patient who is not breathing on his/her own. During a concurrent interview and record review with the DON, on 8/31/23 at 11:30 a.m., the facility's P&P titled "Emergency Procedure - Cardiopulmonary Resuscitation," revised on 2/2018 was reviewed. The P&P indicated, The facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. "1. d Initiate the basic life support [BLS] sequence of events. 2. The BLS sequence of events is referred to C-A-B [chest compression, airway, breathing]. ... 4. Airway. Tilt head back and chin lift to clear airway. 5. Breathing. After 30 compressions [chest] provide 2 [two] breaths via ambubag or manually [with CPR shield]. 6. ... Trained rescuers should provide ventilations [breathing that allows for gas exchange, how the lungs and respiratory system automatically perform this vital process] with compression-ventilation ratio of 30:2." The DON stated, "Staff should have followed the P&P but didn't". The DON further stated an ambu bag is used for patients that are unresponsive to pain, tactile (touch), verbal (in the form of words) and not breathing. The DON stated that checking the rise and fall of the chest was used to check for respirations and when the latter and former are absent, then chest compressions are initiated and delivered in a ratio of 30 (compressions)-to-two (breaths) when there are two staff. The DON further stated that the nonrebreather mask delivers oxygen at a higher concentration to patients that are breathing on their own. The DON stated that if resident was not receiving oxygen, then the brain would not receive oxygen, and would cause brain damage. A review of the American Heart Association Algorithm titled, "Adult Basic Life Support Algorithm for Healthcare Providers" for the year 2020, indicated, " ... No breathing or only gasping [a survival reflex triggered by the brain], no pulse felt, start CPR perform cycles of 30 compressions and 2 [two] breaths. ..." A review of the facility's undated document titled, "Chest Compressions", indicated, " ... When multiple trained personnel are present, the simultaneous performance of continuous excellent chest compressions and proper ventilation using a 30:2 compression-to-ventilation ratio is recommended by the AHA for the management of SCA. The importance of ventilation increases with the duration of the arrest." A review of the facility's undated P&P titled "Manual Ventilation," indicated a manual resuscitation device (Ambu bag) ".... is a self-inflating bag-valve-mask device designed for the manual ventilation of a resident allowing manual delivery of oxygen or room air to the lungs of a patient who can't breathe spontaneously [a process or event occurring without apparent external cause]. 1. Attach oxygen tubing from the manual resuscitation bag to the oxygen tank and adjust the flow to 15 liters per minute [LPM]. 2. ... use the chin lift position and seal the mask around the resident's nose and mouth ... 3. Visually check the manual resuscitator oxygen reservoir bag with your hand using a squeezing motion. 4. Visually check the resident for the rise and fall of the chest. Mask adjustments may be required for a proper seal." A review of the facility's P&P titled "Emergency Procedure - Cardiopulmonary Resuscitation," revised on 2/2018, indicated, "Personnel have completed training on the initiation of cardiopulmonary resuscitation [CPR] and basic life support [BLS], including defibrillation [are devices that apply an electric charge or current to the heart to restore a normal heartbeat], for victims of sudden cardiac arrest." The P&P further indicated, the facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. ... "1. d Initiate the basic life support [BLS] sequence of events. 2. The BLS sequence of events is referred to C-A-B [chest compression, airway, breathing]. ... 4. Airway. Tilt head back and chin lift to clear airway. 5. Breathing. After 30 compressions [chest] provide 2 [two] breaths via ambubag or manually [with CPR shield]. 6. ... Trained rescuers should provide ventilations [breathing that allows for gas exchange] with compression-ventilation ratio of 30:2." The facility failed to ensure LVN 3, performed CPR for Resident 1 in accordance with the facility's undated P&P titled "Manual Ventilation" and undated document titled "Chest Compressions", and the American Heart Association Algorithm titled "Adult Basic Life Support Algorithm for Healthcare Providers" for the year 2020 to implement 30 chest compressions and two breaths. CNA 1 found Resident 1 in bed and unresponsive on 7/18/2023 at 7:35 am. During CPR, LVN 3 placed a non-rebreather mask and administered oxygen at 15 L/min, when Resident 1 was not breathing. As a result, there was lack of oxygenation for Resident 1. The paramedics transferred Resident 1 to GACH via emergency service on 7/18/2023 at 7:43 a.m. Resident 1 died two days later at the GACH. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.